Student-led Doctor of Nursing Practice projects in the clinical environment: Viewpoint from hospital-based nurse scientists and leaders.

BACKGROUND: Exponential increases in Doctor of Nursing Practice (DNP) program enrollment have come with a rapid rise in the number of capstone projects conducted in clinical environments. However, misaligned priorities between students, faculty, and clinician leaders have created significant challenges. PURPOSE: Identify opportunities to strengthen collaboration between academic and clinical stakeholders to better support DNP projects and education. METHODS: Experienced hospital-based nurse leaders engaged in scholarly discourse supplemented by policy and research in DNP education. FINDINGS: Facilitating a DNP project requires significant investment of time, resources, and funds from the healthcare institution. Discord has arisen due to unclear responsibilities or decision-making ability for clinical stakeholders, ethical dilemmas for students who are also employees of the clinical site, and mismatched priorities between clinical need and student/academic project desires. Clinical leaders have raised significant concerns about DNP project proposals that are research-focused, diverge from healthcare institution goals, and lack a sustainability plan. DISCUSSION: Fortification of academic-practice partnerships and clarification of roles in the DNP student project are necessary to ensure that the project is of educational value to the student, a demonstration of learning for faculty, and of sustained clinical value to the healthcare system.

Promoting Nurse Manager Professional Well-being.

Healthcare delivery is increasingly complex, with frontline leader roles, especially the nurse manager (NM), pivotal for success. This role is highly stressful, often leading to burnout influencing job satisfaction and leadership effectiveness. A quality improvement project, including preintervention and postintervention assessment with a focused improvement event for NMs, in a large children's hospital was completed. Organization strategies to support professional well-being and enhance support for the NMs were identified and implemented.

Improving Timeliness of Pediatric Emergency Department Admissions.

INTRODUCTION: The goal of this quality improvement project was to improve timing, communication, and continued care for pediatric patients who present to the emergency department at a Level I pediatric trauma center and require inpatient admission. METHODS: Using continuous improvement methodology, a patient flow process was created to improve the throughput of pediatric patients requiring inpatient admission from the emergency department, aimed at decreasing the time from decision to admit to actual admission. The new workflow included ED and inpatient nursing collaboration, with nursing leaders coordinating patient transfer. RESULTS: Baseline data indicated that, in 2019, patients admitted to a short-stay pediatric unit from the emergency department had an average time of 106.8 minutes from decision to admit to the actual admission. After the implementation of a new admission process, time from decision to admit to actual admission decreased from a mean of 106.8 minutes to 82.84 minutes for patients admitted to a short-stay unit. This illustrates an improvement from 59.75% to 68.75% of patients admitted within 60 minutes from ED admission to arrival on a short-stay unit. This model was then replicated throughout other units in the hospital. DISCUSSION: There are no known benchmark data to guide practice for rapid admission from the pediatric emergency department to inpatient units and continuing care. This quality improvement project demonstrates a model that has been successful admitting patients in an efficient, time-controlled manner. Additional research is needed to document benchmarks for admission timing and to demonstrate other measurable outcomes in patient care.

Evaluation of an Innovative Model of Care for a Limited-Stay Pediatric Unit.

Information about pediatric observation and limited-stay unit design and function is lacking in the literature. A quality improvement approach was used to create new care processes on an inpatient unit within a large children's hospital. Outcomes included the use of advanced practice nurse patient care management, creation of 30 clinical pathways to model care, and consistent and faster transfer from emergency department to inpatient unit, resulting in high-level parent and patient satisfaction and decreased nursing turnover.

PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children.

OBJECTIVE: To determine the safety and feasibility of an early mobilization program in a PICU. DESIGN: Observational, pre-post design. SETTING: PICU in a tertiary academic hospital in the United States. PATIENTS: Critically ill pediatric patients admitted to the PICU. INTERVENTION: This quality improvement project involved a usual-care baseline phase, followed by a quality improvement phase that implemented a multicomponent, interdisciplinary, and tiered activity plan to promote early mobilization of critically ill children. MEASUREMENTS AND MAIN RESULTS: Data were collected and analyzed from July to August 2014 (preimplementation phase) and July to August 2015 (postimplementation). The study sample included 200 children 1 day through 17 years old who were admitted to the PICU and had a length of stay of at least 3 days. PICU Up! implementation led to an increase in occupational therapy consultations (44% vs 59%; p = 0.034) and physical therapy consultations (54% vs 66%; p = 0.08) by PICU day 3. The median number of mobilizations per patient by PICU day 3 increased from 3 to 6 (p < 0.001). More children engaged in mobilization activities after the PICU Up! intervention by PICU day 3, including active bed positioning (p < 0.001), and ambulation (p = 0.04). No adverse events occurred as a result of early mobilization activities. The most commonly reported barriers to early mobilization after PICU Up! implementation was availability of appropriate equipment. The program was positively received by PICU staff. CONCLUSIONS: Implementation of a structured and stratified early mobilization program in the PICU was feasible and resulted in no adverse events. PICU Up! increased physical therapy and occupational therapy involvement in the children's care and increased early mobilization activities, including ambulation. A bundled intervention to create a healing environment in the PICU with structured activity may have benefits for short- and long-term outcomes of critically ill children.

Acute Liver Failure in Children.

Pediatric acute liver failure is a rare diagnosis which can result in death or multiorgan system failure with a potential need for liver transplantation. The causative factors are many, but etiology, definitive pathophysiology, and directed therapies are still under investigation contributing to the difficulty in planning and providing both medical and nursing care. Clinical practice guidelines for acute liver failure are available for adult patients and through a national published position paper for pediatrics, but quality evidence is limited, especially with regard to testing and treatment recommendations, providing challenges in pediatric critical care decision making.

Outcomes of a Pediatric Ultrasound-Guided Short Peripheral Catheter Training Program and Hands-On Poultry Simulation Course.

Ultrasound guidance is an effective technique for obtaining short peripheral catheter (SPC) access but requires training and practice for proficiency. The aim of this quality improvement initiative was to develop and assess a formal training program to increase the confidence and competency of intravenous (IV) therapy nurses in the placement of ultrasound-guided SPCs. IV therapy nurses completed a didactic and hands-on training course where they practiced ultrasound-guided SPC placement techniques on a poultry phantom during simulation, followed by performing ultrasound-guided SPC insertion on patients proctored by an interventional radiology physician. Data collection included preintervention and postintervention confidence self-assessment, frequency tracker, Difficult Intravenous Access (DIVA) scale scores, and total number of ultrasound-guided SPCs placed by the nurses. Ultrasound-guided SPC placement increased significantly after the training program. The IV therapy nurses placed 29 ultrasound-guided SPCs in 2017, 391 ultrasound-guided SPCs in 2018, and 711 ultrasound-guided SPCs in 2019. Mean DIVA scores rose from 4.54 in May 2018 to 5.17 in July 2018, indicating success in placing SPCs in more difficult patients. Implementation of an ultrasound-guided SPC placement program using poultry phantom simulation is a recommended nursing resource for increasing competency in ultrasound-guided SPC placement in pediatric patients.

A Pediatric Nursing Professional Development Team's COVID-19 Response.

The role of pediatric hospitals in the COVID-19 pandemic changed quickly. The team of clinical nurse specialists and clinical nurse educators in a large pediatric hospital were instrumental in the institutional response through simulations, serving as change agents, collaboration, and implementing systems thinking. Leveraging the expertise of this team during this historical and unprecedented time optimized patient and associate safety as part of a pediatric hospital's COVID-19 response.

Ambulatory blood pressure monitoring: A nurse practitioner run program.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) is a standard screening tool for the diagnosis of hypertension in children, adolescents, and adults. However, there is confusion and misunderstanding about which guidelines can provide the most accurate diagnostic values. LOCAL PROBLEM: At a large, free-standing pediatric hospital, ABPM testing was historically being conducted by both nephrology and cardiology departments. The nephrology service was using the American Heart Association (AHA) guidelines, published in 2014 for interpretation of results and for diagnosis of hypertension, whereas the cardiology service depended on the 2004 National High Blood Pressure Education Program (NHBEP) fourth report, which led to discrepancies in diagnosis of hypertension in this patient population. METHODS: A nurse practitioner-led quality improvement project was designed and implemented to determine the best method of ABPM monitoring and test interpretation based on comparing results of patients using height, gender, and application of either the 2004 NHBEP fourth report or 2014 AHA guidelines. INTERVENTIONS: Using a retrospective chart review, ABPM monitoring results from both cardiology and nephrology services were reviewed and compared to identify the most accurate methods and to recommend changes to practice. RESULTS: Accuracy of interpretation for ABPM is best accomplished using the 2014 AHA guidelines. CONCLUSIONS: Using a single method of interpretation provides consistent diagnosis and treatment of hypertension in children. Nurse practitioners can apply this knowledge in other settings to manage hypertension and provide similar services in different settings, including primary care.

Pediatric Quality Metrics Related to Quality and Cost.

The institution of pediatric quality in health care has grown in the past decade but continues to evolve. Children's health care emphasizes the importance of maintenance of health and prevention of illness, which can be measured based on immunization rates, routine or scheduled well care, and early intervention. Pediatric quality measures and indicators have become the basis for payment of services and a true goal to value. Designing processes such as pay-for-performance models, volume-based care, and coordination of care assist in assuring that children receive high-quality health care.

Preventing ventilator-associated pneumonia in children: an evidence-based protocol.

Ventilator-associated pneumonia, the second most common hospital-acquired infection in pediatric intensive care units, is linked to increased morbidity, mortality, and lengths of stay in the hospital and intensive care unit, adding tremendously to health care costs. Prevention is the most appropriate intervention, but little research has been done in children to identify necessary skills and strategies. Critical care nurses play an important role in identification of risk factors and prevention of ventilator-associated pneumonia. A care bundle based on factors, including evidence regarding the pathophysiology and etiology of pneumonia, mechanical ventilation, duration of ventilation, and age of the child, can offer prompts and consistent prevention strategies for providers caring for children in the pediatric intensive care unit. Following the recommendations of the Centers for Disease Control and Prevention and adapting an adult model also can support this endeavor. Ultimately, the bedside nurse directs care, using best evidence to prevent this important health care problem.